Life-Threatening Allergy Management Plan Template
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2Life-Threatening Allergy Management Plan
To be completed by MD: Valid for Current School Year ________________
Name: ___________________________________ DOB: _____________Weight______
Allergy to:
__________________________________________________________________
Asthma: □ Yes (high risk for severe reaction) □ No
□ See Asthma Action Plan
Extremely Reactive to:_________________________________________________________________
If known exposure, give epinephrine immediately and call 911.
Action for Mild Reaction:
Liquid
□ diphenhydramine
p.o.
(12.5mg//5ml)
Systems:
Symptoms:
(can be repeated q 4-6 hours)
Mouth:
itchy mouth
□ cetirizine
p.o.
(5mg/5ml)
Skin:
minor itching “and/or” a few hives
(do not repeat)
Dose:____________________
Gut:
mild nausea/discomfort
Stay with student. Alert parent. If symptoms worsen then follow steps for major reaction.
Action for a Major Reaction: (two systems or single severe symptom)
Systems:
Symptoms:
MOUTH
swelling of the lips, tongue, or mouth
THROAT
tight throat, hoarseness, drooling, trouble swallowing
LUNG
shortness of breath, repetitive cough and/or wheezing
HEART
thready pulse, faint, confused, dizzy, pale, blue
SKIN
multiple hives, swelling about the face and neck
GUT
abdominal cramps, vomiting
1. Inject Epinephrine immediately intramuscularly
□ Epipen® □ Epipen® Jr □ Auvi-Q™ 0.30mg □ Auvi-Q™ 0.15mg □ __________
2. Call RESCUE SQUAD 911 ASK FOR ADVANCED LIFE SUPPORT
•
Students should not suddenly sit up, stand or be placed in the upright position.
This increases risk for sudden death.
3. Note time epinephrine was given and repeat dose after 5 minutes if no improvement or
worsening symptoms.
• Antihistamines and inhalers are not first line therapy in a severe reaction.
4.
Transport via EMS to the emergency department.
Emergency Contacts:
Parent/Guardian____________________________________________ Phone:______________________
Other emergency contact______________________________________Phone:______________________
________________________
_________
_________________________
_________
Parents Signature
DATE
DATE:
DOCTOR’S SIGNATURE
________________________
__________
Print MD Name: ___________________________________
Nurses Signature
DATE
Contact number: __________________________________
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